Provider Demographics
NPI:1922443720
Name:LUCIA, JUSTINE R (LMT)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:R
Last Name:LUCIA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61183 FIR CREST KNL
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2568
Mailing Address - Country:US
Mailing Address - Phone:541-647-0493
Mailing Address - Fax:
Practice Address - Street 1:222 SE URANIA LN
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1624
Practice Address - Country:US
Practice Address - Phone:541-647-0493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17408225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORLMT 17408OtherOREGON LICENSE